Serious Case Review into the death of Child 'F'

Wolverhampton Safeguarding Children Board has today (Thursday 6 April, 2017) published the findings of a Serious Case Review into the death of a baby boy.

The infant, referred to as Child F, suffered a serious head injury and multiple fractures in October 2015 when he was two weeks old. He died from his injuries a few weeks later. The child's father was subsequently jailed for life for murder and told he will serve a minimum of 15 years.

The Serious Case Review (SCR) was commissioned in late 2015 by Wolverhampton Safeguarding Children Board to ascertain the involvement of agencies with Child F and his family and determine what could be learned.

Alan Coe, Chair of Wolverhampton Safeguarding Children Board, said: “The death of any child is a tragedy. It is even more so when that child was killed as a result of a violent act committed by his father.

"Parents have a duty to care for, nurture, and love their children. The father failed this little boy and this was reflected in the life sentence he received from the courts.

“Professionals involved in the care of children always want to know what they can do better to improve the ways they work together to protect children. The Serious Case Review process is one way in which practitioners are able to reflect and learn.”

“The report makes it clear that there was no evidence that the injuries which caused the little boy’s death could have been anticipated. However, it does identify a number of ways in which, in similar circumstances, more opportunities might be taken that could enable professionals to better coordinate and share information and to identify potential risks.

“None of that means we can guarantee a death in similar circumstances might not occur again, but it is important to analyse what we can learn from such a tragedy and, by taking action, reduce the likelihood of it happening again.”

Among those agencies involved in the review were the City of Wolverhampton Council, Royal Wolverhampton NHS Trust, West Midlands Police, Birmingham Children's Hospital NHS Foundation Trust and the National Probation Service.

The Serious Case Review overview report, written by independent reviewer and author Keith Ibbetson, makes a total of 12 recommendations that are being implemented by Wolverhampton Safeguarding Children Board and a number of the agencies involved.

These include ensuring child and family assessments, including pre-birth assessments, are both high quality and effective; reviewing safeguarding arrangements in the Emergency Department and antenatal services at New Cross Hospital; improving the quality of primary health visits; and that agencies are aware of their responsibilities for pre-birth identification, referral and assessment of need.

It also recommends reviewing the actions of agencies to involve fathers and male carers in safeguarding work; understanding the potential impact that reorganisation by agencies can have on service provision; and ensuring new and prospective parents are given clear messages about the dangers of shaking their baby.

Contributing agencies also made a number of other improvements to policies and practice during the course of the review.